The purpose is to evaluate practice variation at the emergency department in comparison with best practice for brain imaging in children presenting with headache. The results of the study might be used to inform a clinical prediction rule in order to better stratify risk according to the American College of Radiology Appropriateness Criteria.
I created a poster for presentation and am currently working on a paper for publication in a scholarly journal.
College Call Girls Pune Mira 9907093804 Short 1500 Night 6000 Best call girls...
Audit of Appropriateness for Brain Scan Use for Paediatric Headache at the Emergency Department
1. Audit of Appropriateness: Brain
Scan Use for Paediatric Headache
at the Emergency Department
Lyndon Woytuck1, Meghan Linsdell2, Lawrence Richer2,3
1St. George’s University of London medical programme delivered by the University of Nicosia
2Women’s and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada
3Department of Pediatrics, Division of Neurology, University of Alberta, Edmonton, AB, Canada
3. PURPOSE
• To evaluate appropriateness and outcomes at the emergency
department in comparison with best practice for brain imaging
in children presenting with headache.
4. YOU WILL LEARN
• How well the emergency department images children presenting with headache
• That we catch most important diagnoses (i.e. brain tumour)
• We overexpose children to radiation
• Studies suggest this is common worldwide
• We can improve
5. THE PROBLEM
• Guidance: American College of Radiology Appropriateness Criteria on headache
• low risk (usually not appropriate)
• high risk (usually appropriate)
• Are the criteria useful / do they match diagnosis?
• Can we learn from our mistakes?
6. METHODS
• Searched ED records: ICD “Headache”
• Excluded head trauma in last 7 days
• 645 patient visits over 1 year from Feb 1 2014 – Jan 30 2015
• Stollery Children’s Hospital, Edmonton, Canada
• Stratified –
“usually NOT appropriate”, “MAYBE appropriate”, “USUALLY appropriate”
• Compared imaging results
7. IMAGING COMPARED TO CRITERIA
Appropriateness
Rating Category
Number of
Cases
Proportion Imaged Important
Abnormalities
Incidental
Abnormalities
Usually not appropriate 412 9.7%
n=40, CI 9.3-10%
1.7%
n=7, CI 1.2-2.2%
1.5%
n=6, CI 1.0-1.9%
May be appropriate 156 28%
n=44, CI 27-29%
2.6%
n=4, CI 1.3-3.8%
1.3%
n=2, CI 0.0-2.5%
Usually appropriate 77 56%
n=43, CI 55-57%
30%
n=23, CI 28-32%
5.2%
n=4, CI 2.8-7.6%
Table 1. Number of cases sent for neuroimaging acquisition and
relevant findings according to appropriateness rating. Number
(n) and 95% confidence intervals (CI) included.
8. RESULTS
Most patients that presented to the ED with headache did not receive neuroimaging
o CT scans are overused
o Some high risk patients did not receive brain imaging
Most cases handled appropriately
Could make predictions as per Appropriateness Criteria
9. DISCUSSION
• Compared Hong Kong Study; the Stollery scanned less
• Compared to Pakistan Study: similar CT overuse in migraine
• Imaging all catches diagnoses, both important and benign pathology
• MRI underused –
no radiation risk + higher yield, BUT expensive + high demand
• Better record-keeping, guidance usage, clinical rules could help!
• “Better safe than sorry” + parental anxiety
10. MISTAKES CLINICIANS MAKE
• Missing warning signs: high risk patients
• CT imaging due to anxiety
• Not vetting “medium risk” patients
• Not referring to guidance
11. WHAT YOU CAN DO
• Use CT less, and MRI more
• Strongly consider past history and aetiology
• Primary or Secondary?
• Neuro signs / symptoms?
• Red flags?
• Use imaging criteria! ACRAC or local guideline
• Remember: imaging rarely changes diagnosis
How good is the emergency department in brain imaging children presenting with headache?
Do we catch the important diagnoses (i.e. brain tumour)?
Do we overexpose children to unnecessary radiation?
How does this compare to other study findings?
How can we improve this process?
Brain imaging: computed tomography (CT) or magnetic resonance imaging (MRI) scan
American College of Radiology Appropriateness Criteria based on signs and symptoms
low risk (usually not appropriate)
high risk (usually appropriate)
Retrospective study: 645 patient visits over 1 year from Feb 1 2014 – Jan 30 2015
At the Stollery Children’s Hospital, Edmonton, Canada
“The ACRAC classifies headaches into five variants:
1. Isolated headache. These are headaches unaccompanied by neurologic signs and symptoms or historical data.
2. Headaches with positive neurologic signs or symptoms, including papilloedema, gait disturbance, abnormal reflexes, cranial nerve findings, altered sensation, nystagmus, or confusion.
3. Headaches with supporting historical data, such as diplopia, morning vomiting; headache that awaken the patient from sleep; intense, prolonged, and incapacitating headaches with an absent family history for migraine; headaches that are increasing in frequency, duration, and intensity; vomiting.
4. Acute severe (thunderclap) headache. And absence of family history of migraine.
5. Common or classic migraine with no neurologic findings.” Nawaz, et al.
Compared to the Tuen Mun Study, the Stollery’s ED scanned less frequently, Kan, et al.
“Out of the 100 patients only 4% patients showed abnormal findings on CT scan while the remaining 96%
of the scans were absolutely normal. The four patients with abnormal findings all had sinusitis no
notorious lesions.” Nawaz, et al.
More medically important cases found
CT overuse is an issue
MRI underused? – no radiation risk + higher yield, BUT expensive + high demand
Better record-keeping, guidance usage, clinical rules could help!
“Better safe than sorry” + parental anxiety
CT scanning is overused for headache in children
Consider past history and aetiology of headache
Primary or Secondary?
Neuro signs / symptoms?
Red flags?
Scans rarely change diagnosis